Looking forward – July 2018

David B. Hoyt

David B. Hoyt, MD, FACS

Helping surgeons and their institutions improve the quality and safety of surgical care always has been and will remain forever at the heart of all American College of Surgeons (ACS) programs. Over the last few years, we have accelerated these efforts and have developed a defined strategy for moving ACS Quality Programs forward in a cohesive and coordinated manner.

These programs and details about their growth will be discussed later this month at the 2018 Quality and Safety Conference, July 21−24 in Orlando, FL. In this column, I provide my perspective on the status of ACS Quality Programs and where they are headed.

The red book

All ACS Quality Programs are grounded in the following four principles: establish the standards, build the infrastructure to support the standards, develop databases to measure performance against those standards, and provide external peer-review verification. Last year, the ACS released Optimal Resources for Surgical Quality and Safety, also known as the “red book,” which seeks to tie these four principles together and to provide a road map for institutions to use on the journey to better outcomes.

This manual, released at last year’s Quality and Safety Conference in New York, NY, outlines all of the factors that the College’s 105 years of experience have shown to influence patient outcomes, including details on the personnel and committees that should be in place, the quality improvement (QI) process, disease management, regulatory issues, data collection and analysis, and the educational requirements for members of the surgical care team. The manual also emphasizes the responsibilities of the individual surgeon.

At press time, the College leadership was working to take the red book to the next logical level and developing standards for verifying and accrediting institutions as compliant with the red book. In other words, the red book provides the road map for developing QI programs, and the standards manual will help set the requirements for institutions to achieve external peer-review verification.

An additional track has been added to the agenda for this year’s Quality and Safety Conference, which will be dedicated to the red book. Sessions in this track will explore concepts and resources from the manual, information on QI tools, methodology, nomenclature, and organizational design and infrastructure.

Status of ACS Quality Programs

Many institutions already recognize the value of participating in the College’s Quality Programs. At present, 2,700 hospitals participate in ACS QI programs, including the National Surgical Quality Improvement Program (ACS NSQIP®), the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), the Commission on Cancer (CoC), the Committee on Trauma (COT), and the National Accreditation Program for Breast Centers (NAPBC). A combined total of 4,000 ACS QI programs are in place throughout the U.S. and Canada.

Many institutions that participate in these programs have significantly reduced surgical site infections and other complications. In fact, 82 percent of participating hospitals have experienced decreased complications, and 66 percent have seen decreased mortality. On average, hospitals have prevented 250 to 500 complications annually. If implemented at 4,500 hospitals, the potential savings are $13 billion to $26 billion per year.

At the core of several of these programs are clinical registries that provide participating institutions with risk-adjusted outcomes data. These data provide a scientifically validated means of determining what factors may have influenced a negative outcome, of pinpointing outliers, and engaging in root cause analysis.

Furthermore, the data extracted from ACS databases have been used in clinical studies that have been published in leading medical and surgical journals. In the last 20 years, the CoC’s National Cancer Database has been cited in 566 peer-reviewed publications, and the COT’s National Trauma Data Bank®/Trauma Quality Improvement Program has been cited in 789 peer-reviewed publications. In addition, ACS NSQIP has been cited in 910 such journals in the last 15 years. That’s a total of 2,265 peer-reviewed publications, for an average of more than 100 citations annually and approximately one every three days.

Another important facet of ACS QI programs is accreditation. The CoC, COT, MBSAQIP, and NAPBC all have programs for surveying and verifying institutions that provide cancer, trauma, bariatric surgery, and breast care.

What’s next?

Right now, some of these programs are undergoing some refinements. We plan to retool the CoC’s accreditation program to incorporate new guidelines and standards. MBSAQIP will continue to evolve, and the COT is rewriting its standards. In addition, we anticipate that some of the quality programs that have launched in recent years will continue to progress.

One example is the Children’s Surgery Verification program. This initiative ensures that hospitals that provide pediatric care have the appropriate resources to provide surgical care to patients younger than 18 years old.

In addition, the Coalition for Quality in Geriatric Surgery’s Geriatric Surgery Verification and Quality Improvement Program is now being piloted in eight centers. Funded with a four-year grant from the John A. Hartford Foundation, the goal of this project is to develop and implement a Geriatric Surgery Verification and Quality Improvement Program. This program will provide a framework for the optimal care of the geriatric surgical patient, generalizable to more than 4,000 facilities regardless of size, location, or teaching status.

Furthermore, the ACS and other organizations, including the Society of Thoracic Surgery and the Society for Vascular Surgery, are collaborating to develop specialty-specific quality programs. The ACS also is working with the American Association for the Surgery of Trauma to develop standards for emergency surgery with ACS NSQIP support.

Other quality programs that the ACS has helped to develop and implement more recently to improve the care of the surgical patient include Strong for Surgery and the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR) program. Strong for Surgery, originally developed by surgeons in Washington State, empowers hospitals and clinics to integrate checklists into the preoperative phase of care to screen patients for potential risk factors that can lead to surgical complications and to provide appropriate interventions to ensure better surgical outcomes. The AHRQ Safety Program for ISCR will support hospitals in implementing perioperative evidence-based pathways to meaningfully improve clinical outcomes and reduce hospital length-of-stay for colorectal, orthopaedic, gynecology, emergency general surgery, and bariatric patients.

Learn more

Of course, none of this would be possible without the leadership of Clifford Y. Ko, MD, MS, MSHS, FACS, and his team in the ACS Division of Research and Optimal Patient Care. To learn more about these initiatives and how you can use ACS Quality Programs to improve patient care, be sure to attend the second annual Quality and Safety Conference. This year’s program is certain to be a rewarding opportunity to learn from experts in the field and to network with other surgeons who are as dedicated to patient care as you are.


If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at lookingforward@facs.org.

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